Question

The Quality Improvement Team at your local hospital is investigating the case of Mr. Baum, who was recently admitted for respiratory difficulties but experienced other health problems while undergoing treatment. The goal of the team is to identify errors and systems issues/failures that affected and prolonged Mr. Baum’s hospitalization. The team will then suggest process improvements that will reduce the likelihood that these errors/failures will happen again in the future. Read "The Case of Mr. Baum (PDF)." Create a fishbone diagram of this case for the Quality Improvement Team. You may download and use the Fishbone Template (Word). Identify process improvements that could reduce the likelihood that these errors/failures will recur in the future.

Answer 1

The process improvements that could reduce the likelihood that these errors/failures will recur in the future include;

Monitoring the vulnerable populations such as; patients in isolation have less contact with healthcare professionals or patients having a language barrier.

Promoting interdisciplinary collaboration

Engage patients in safety, for example, a direct communication of the patient with the healthcare provider be it a nurse, doctor or the pharmacist.

Encourage a high-reliability culture as the healthcare leaders should help ensure staff members are comfortable in communicating the knowledge of medical errors that have occurred, as well as opportunities for medical errors, within their organizations